On July 6, 2013, a runaway train with 72 tanker cars filled with crude oil crashed and burst into flames in the small Quebec town of Lac-Mégantic. The ensuing explosion and massive fire killed 47 people, destroyed 50 buildings and burned nearly 60 vehicles. The TSBC launched an intensive yearlong investigation into causes of the crash, and the final report revealed that 18 different factors, including inconsistent oversight from the Canadian government, led to the accident.

“Accidents never come down to a single individual, a single action or a single factor. You have to look at the whole context,” said Wendy Tadros, chair of the TSBC.

The report identified and criticized a lax corporate “culture of safety” at the Montreal, Maine and Atlantic Railway (MMA) as a primary contributing factor to the disaster. The TSBC investigators concluded that the MMA did not have a functioning safety management system in place to manage risks. The TSBC report revealed that the railroad routinely cut corners, such as opting to operate trains at lower speeds rather than make repairs to rusted and cracked rails.

During the course of their investigation, officials with the Canadian safety board learned that Transport Canada, a government agency, did not audit the MMA often or thoroughly enough to ensure the company was effectively managing its safety risks. In addition, the report identified signs of a weak organizational safety culture at the MMA, such as:

Management’s acceptance of track wear that was well beyond industry norms and the company’s own standards.

Management’s tolerance of nonstandard repairs to locomotives and train cars.

A systemic practice of leaving trains unattended for several hours without in-depth procedures to prevent uncontrolled movements.

An inadequate recertification program and training that did not ensure that crews knew and understood procedures for safely securing trains.

The MMA was a small regional U.S.-based railway that operated in Quebec, Vermont and Maine. For years, the railway’s primary business had been transporting forestry-related products; however, the company had struggled with financial difficulties since 2002 when a regional paper plant—a key customer—closed down. According to sources familiar with the issue, the railroad in recent years had been hauling an increasing number of tanker cars filled with crude oil.

The railroad filed for bankruptcy just a few weeks after the deadly derailment, and Railroad Acquisition Holdings LLC purchased the MMA’s remaining assets in a January 2014 auction. Three former employees of the now-defunct railroad were arrested by Quebec police and face charges of criminal negligence.

“The investigation and its findings are complex, but our goal is simple: We must improve rail safety in Canada,” Tadros said. “This is about governments, railways and shippers working together and doing everything in their power to ensure there is never another Lac-Mégantic.”